Making sure women throughout the world can give birth in a health facility, in the presence of a midwife, is the best strategy for substantially reducing maternal mortality worldwide, according to a landmark series of papers published by The Lancet today (Thursday September 28, 2006). The authors are calling on governments and donors to prioritise this strategy over alternatives, such as home births with a relative, traditional birth attendant, community health worker or midwife. The five papers that form the Lancet maternal survival series present the evidence for prioritising the health centre strategy and detail the action required for its roll-out, including immediate actions for governments and donors. The authors warn that without political commitment and investment into this approach, substantial declines in maternal mortality are unlikely in the next 10-20 years, and the fifth Millennium Development Goal  to reduce maternal mortality by 75% by 2015  will not be met.

Over half a million women die in pregnancy or childbirth each year. The first paper in the Series reveals the stark disparities that exist between rich and poor countries; women in the poorest parts of the world are over 1000 times more likely to die from maternal causes than those in developed countries. For every 30000 women in Sweden, one will die from pregnancy-related complications. In sub-Saharan Africa the average figure is a staggering one in 16 and in South Asia one in 43  the regions with the greatest burden of maternal deaths worldwide. The paper also highlights that most pregnant women die in labour, delivery, or during the 24 hour period after delivery, mainly from severe bleeding and hypertensive disorders. Midwives have the skills to prevent around 88-98% of these deaths but currently, over half the world's women deliver their babies without professional care.

The second paper in the Series assesses the different strategies for reducing maternal mortality. It reveals that the provision of professional care in a health centre is more effective than alternative approaches and has the potential to bring maternal mortality below 200 per 100 000 live births. The paper also emphasises that complementary opportunities exist to reduce maternal mortality through antenatal care, family planning and, where possible, safe abortion.

"There is a move towards the professionalisation of childbirth but despite these trends, millions of women are left without care. Nearly one in 4 women in developing countries continue to be either alone or only with a relative to assist them at childbirth and this has not changed since the early 1990s." says Carine Ronsmans, a Series author from the London School of Hygiene and Tropical Medicine (LSHTM).

Midwives working in health centres can oversee a larger number of deliveries and can ensure cleanliness, detect complications early, facilitate referrals for emergency care more easily (e.g. for blood transfusions, caesarean sections), and often can call on colleagues for support. Projections, using data from Bangladesh, suggest that teams of midwives and midwife assistants working in health centres can increase the proportion of women with professional care by 40% by 2015. Professional care will also benefit infants because midwives have the skills to resuscitate newborns, ensure they are kept warm, detect infections, and promote early exclusive breastfeeding.

The Series authors therefore recommend that further investments for maternal survival prioritise the health centre strategy. Governments should not invest in community health workers at the expense of funds for skilled attendants in health facilities, they state.

In a Comment to introduce the Series, Richard Horton, Editor of The Lancet, states that over the past 20 years, a series of strategic errors--focusing only on mothers at risk of complications and relying on traditional rather than skilled birth attendants, have stifled progress in safe motherhood.

The third paper in the series looks at what is needed to scale-up professional care worldwide. The author's state that the immediate priority for governments and donors should be to invest in the training, deployment and retention of skilled attendants, especially midwives. The sheer lack of staff and facilities is the most substantial barrier to progress in many developing countries. Retention of workers is a major part of the supply problem; marked migration is seen in several sub-Saharan countries. In Ghana, for example, annual outflow of registered nurses to the UK increased 6 times during the 5 years before 2003. Governments need to invest in efforts to retain staff, improve working conditions, and offer incentives for good quality care, state the authors.

Estimates suggest that nearly three times the current number of professionals, about 700 000 more, are needed for full coverage of professional care for women by 2030. By 2015, 73% coverage could be achieved if 334 000 more health-care professionals with midwifery skills were recruited. To support them 24 000 birthing units in health centres, 27 000 doctors and technicians, and 11 000 maternity units in hospitals would be needed. To achieve this level of services, funding is needed from both donors and governments of an additional US$1 billion per year in 2006, increasing to US$6.1 billion in 2015.

"The challenge of reducing maternal deaths will require long-term support, and by long-term, we mean at least ten years, and probably longer. Donor investment will be vital, as will resource-tracking mechanisms to hold all countries, donors, and other actors to account," state the authors.

"Women throughout the world should have the choice of delivering with a skilled attendant. If professional care is provided then the chances of survival for mothers and infants improve. Although some women may choose alternative approaches, research shows that most seek professionally provided maternity care when they have access to it and can afford it," states Oona Campbell, a Series author from LSHTM.

Currently, many households do not seek professional care at delivery because they cannot afford the costs, according to the fourth paper in the Series. To make the health centre strategy work, health care fees for mothers need to be removed and where insurance schemes exists, maternity care should be included in the benefits package, state the authors. Funds also need to be made available to the poorest women to assist with costs of transport to a health facility.

Dr Horton comments: " the appalling neglect of motherhood as both a health issue and a fundamental human right has provoked agencies and professional associations to begin to lay a foundation for country action. The purpose of this Lancet series is to go one step further: to establish and bring together the essential factual prerequisites for implementation of programmes to reduce the preventable and unacceptable toll of maternal deaths. There can be no safe future for our species without healthy motherhood."

In the final paper of the Series, the authors summarise the action required and state that the new Partnership for Maternal, Newborn, and Child Health, is best placed to lead a revival in efforts to ensure safe motherhood. Director of The Partnership, Francisco Songane, states: "Let us take stock of the past 20 years: We have not made Motherhood Safer--as promised in Nairobi in 1987. In fact, the rate of maternal deaths is the same or worse in some parts of the world like Africa. Decision-makers must act now to ensure that every delivery is a safe delivery-- and that mothers everywhere must not pay with their lives when giving birth."

The strategy:

To ensure women through out the world can give birth in a health facility in the presence of a midwife.

Why?

This strategy will be more effective and save the lives of more mothers and babies than home births with a relative, traditional birth attendant, community health worker or midwife. Estimates suggest that this approach could bring maternal mortality below 200 deaths per 100 000 live births.

How?

Governments and donors need to prioritise the health facility delivery strategy over others.

Governments and donors must increase their financial support to maternal health by an additional US$1 billion per year in 2006 to a level of US$ 6.1 billion in 2015 to substantially improve worldwide coverage of maternal services.

Track progress in improving maternal health and services to encourage and monitor government and donor commitments.